8536 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENT[FICATI ON PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8536
OWNER'S PLAN CHECK VALIDATION
Onn NAME _ ELECTRIC PERMIT FEE
• PHONE
NAAMERADTDrs OUTLETS-SWITCHES-RECEP 10.00/1.00
)a fixtenuc.NO. 7 LIGHTING FIXTURES 10.00/1.00
ADDRESS RE �..} APPLIANCES-RESIDENTIAL 4.00
y- PHONE �7- / PANELS 10.00 DATE OF APPLICATION
i
OR
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG SPECIALCIRCUIT 5,00 LIDATION
ZIP TEMP.METER OR POLE INS. 20.00
POR ANTS MOTORS SEE FEE SCH. JUN 5 1985
SERVICE CHANGE 20.00
r o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00 City of Cupertino
av I hereby affirm that I am licensed under provisions of Chapter 9
2 w ISSUANCE DATE
y Gn (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. C .
F 7 i Professions Code,and my license is in full force and effect. El 1:1
E]z o T License Class Lia Number
o O Datc Contractor
F r J
¢ ac w a OWNER-BUILDER DECLARATION BUILDING PERMIT
o' U MISC.- REFER TO ORD INFORMATION
F
; u_1- I hereby affirm that I am exempt from the Contractor's License VALUATION $/FT.
LL o¢ Law for the following reason.(Sec.7031.5,Businessand Professions 10.00
- J PERMIT ISSUANCE
Code:Any city or county which requires a permit to construct,alter,
al Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
-m u requires the applicant for such permit to file a signed statement that TOTAL REIT TO
La he is licensed pursuant to the provisions of the Contractor's License /
Fii Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
X F-a the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
Ur by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(5500).):
❑ 1,as owner of the property,or my employees with wages as BACKFLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the s[ruchve is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CONO. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds ar improves thereon,and who does such work FIXTURES• -PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve-
ments are not intended or offered for sale,If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner,
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale.). RES IND' CON PB Other
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 C1licensed contractors to construct tile Project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply V.B.. .
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lamexemptunder Sec. ,B.&P.C.for this
reason WATER HEATER WIVENT 6.00
Owner Date WATER SYSTEM ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to sell'-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
ompany
`❑ Certified copy is hereby furnished. FIRE$PRINK ENERGY T20
Z Z yO/CeRified copy is filed with the city inspection division.
F 0 AlEpliiaat MISC.- REFER TO ORD. Y N El Y ❑ NC]
IFN CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 ,,XI FLOOD ZONE A.L.u.C.
UJ > COMPENSATION INSURANCE PLG.CONTR.CL LIC NO. PLO,
2 (This section need not be completed if the permit is for one TOTAL D Y[:] N❑ Y [:] NF]
handled dollars($100)or lean)
U O 1 certify that in the performance of the work for which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California,
0- Date Applicant- BUILDING
ALTER OR ADD TO MECH. 5.00
>_ 0 NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
G such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10PC CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 110MCEM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EATI N G U N IT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that 1 have read oris application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING
ordinances and slate laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 gTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00
granting of this permit. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY